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Repro > Complicated Pregnancy 2 > Flashcards

Complicated Pregnancy 2 Flashcards

Ectopic Pregnancies Early Labour

1
Q

What are the most common locations for an ectopic? [4]

A

Tubal: ampullary > isthmus > intramural (97% )

Ovarian (1% )

Cervical (0.1%)

Fimbrial (~%)

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2
Q

Ectopic pregnancy risk factors [7]

A

Risk factors include:

  • PID
  • Tubal surgery
  • Previous ectopic
  • Assisted conception e.g. IVF
  • IUD
  • Progesterone only pill
  • Endometriosis
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3
Q

Presentation of ectopic pregnancy [3]

A
  1. Hx of amenorrhea for 6-8 weeks with positive urine pregnancy test
  2. Leading symptom: unilateral iliac fossa pain, with/without vaginal bleeding
  3. Other symptoms: loos stool, vomiting
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4
Q

How do we test to confirm an ectopic? [5]

A
  • FBC, G&S
  • Serum progesterone (usually sub-optimal)
  • Serum b-HCG serially tracked at 48 hour intervals
  • Rhesus status

Ultrasound findings:
- No intrauterine sac, may see an adnexal mass and/or blood in the Pouch of Douglas

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5
Q

What does Serum BHCG tell us about an ectopic [2]

A

Normally, increases by at least 66% in 48h

However in ectopic will rise sub-optimally

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6
Q

How can you treat an ectopic pregnancy?

A

1) Conservative (if she’s stable it may shrink on its own) - monitor b-HCG levels to ensure falling
2) Medical - MTX
3) Surgical - Laparoscopic salpingectomy if there’s a risk of rupture and/or very unstable

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7
Q

Define preterm labour [1]
Gradings [3]
Types of preterm labour [2]

A

the onset of labour before 37 completed weeks

Mildly preterm = 32-36wks
Very Preterm = 28-32 wks
Extremely Preterm = 24-28wks

Preterm labour can be both spontaneous or Induced

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8
Q

Predisposing factors of preterm labour [4]
Causes [3]
Diagnosis of preterm labour [2]

A

RF

  • Multiple pregnancy
  • Polyhydramnios
  • Smoking
  • Pre-eclampsia

Causes

  • APH
  • Infection e.g. UTI
  • Premature membrane rupture

Diagnosis
Contractions before 37w
Cervical changes on vaginal examination

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9
Q

How do we go about managing a pre-term labour that is viable? [4]

A
  • Tocolysis
  • Steroids
  • NICU transfer
  • Aim for vaginal delivery
  • Counselling for family, MDT with neonatologist
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10
Q 
What is Tocolysis and when do we use it?
Give 3 eg and their respective class of drug
A

Tocolysis encompasses labour suppressant meds.
You can use it for up to 24hrs in order to transfer the patient to a facility with a NICU & to give steroids

Nifedipine – CCB
Atosiban (IV) – oxytocin antagonist
Terbutaline – beta 2 agonists
Indomethacin

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11
Q

Why give steroids in pre-term labour? [2]

ROA, doses [2]

A

increases rate of lung development by increasing surfactant development

IM dexamethasone 2 doses 24h apart

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12
Q

What are the common complications of prematurity for the neonate? [6]

A
  • Resp Distress Syndrome
  • Intraventricular hemorrhage
  • Cerebral Palsy
  • Jaundice
  • Infections
  • Visual or hearing impairment

Also temp control and nutrition are very difficult for premature babies

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13
Q

What is one symptom in ectopic pregnancies to watch out for?

A

irritation of diaphragm by blood in peritoneal cavity > referred pain because diaphragm and supraclavicular nerves that innervate shoulder tip share C3-C5 dermatomes

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14
Q

Ectopic pregnancy uncommon presentations
Vaginal bleeding - explain and most common bleeding sites
Vaginal discharge

A

Vaginal bleeding caused by decidual breakdown in the uterine cavity due to suboptimal beta-HCG levels.
Bleeding usually intra-abdominal not vaginal
Vaginal discharge – brown colour akin to prune juice – result of decidual breakdown

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15
Q

Ectopic pregnancy uncommon presentations
Abdominal exam may reveal, why
Bimanual exam signs [3]

A

Localized abdominal tenderness due to peritoneal irritation

Normal sized uterus
Cervical excitation
+/- adnexal tenderness

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16
Q

Ectopic pregnancy uncommon presentations

State the 5 signs of hemodynamic instability

A

pallor, increased capillary refill time, tachycardia, hypotension, signs of peritonitis

17
Q

Surgical Management of ectopic pregnancy
Advantage [1]
Disadvantage [3]
Salpingectomy vs salpinotomy

A

Salpingotomy or salpingectomy

Advantage: high success rate

Disadvantage:

  • Gen Anaesthesia risk
  • risk of adnexal damage
  • salpingotomy still has risk of tx failure as some of pregnancy may remain
  • Salpingectomy: if other tube healthy
  • Salpingotomy: if other tube not healthy
18
Q

Management of preterm deliveries occurring <24-26 weeks - generally regarded as very poor prognosis

A

Discuss with parents and neonatologist to make decisions…

19
Q

Gestational trophoblastic disorders define [2]
Ax [1]
Symptoms [3]

A

Spectrum of disorders ranging from partial hyatidiform mole to choriocarcinoma

Ax: benign tumour of trophoblastic material

Sy/Si:

  • bleeding in 1st or early 2nd trimester (heavy, frogspawn appearance)
  • exaggerated symptoms of pregnancy e.g. hyperemesis, uterus large for dates
  • may be hypertensive or hyperthyroid
20
Q

Gestational trophoblastic disorders
Pathophysiology
Classificaiton [2]

A

Px: large chorionic villi with overgrowth of trophoblastic cells

  • Complete mole: empty egg fertilised by sperm that duplicates its own DNA, hence all 46 chromosomes are from the male
  • Partial mole: normal haploid egg fertilised by 2 sperms or one sperm with duplication of paternal chromosomes; leading to triploid e.g. 69XXX or 69XXY; may have fetal parts
21
Q

Gestational trophoblastic disorders
Ix [2]
Mx [4]
Cx [1]

A 
Ix: 
- serum beta hCG (very high levels)
- USS (snowstorm appearance)
Mx: 
- urgent referral to specialist centre for evacuation of uterus (Cx: thyrotoxic storm)
- bHCG is monitored for 6m
- METHOTREXATE if remains high
- effective contraception to avoid pregnancy for 1y after 
Cx: choriocarcinoma (2-3%)
22
Q

PPROM
Define
Complications: fetal [3], maternal [1]
Investigations [4]

A

Preterm prelabour rupture of the membranes: amniotic membrane ruptures before week 37 of pregnancy.

Complications of PPROM

  1. fetal: prematurity, infection, pulmonary hypoplasia
  2. maternal: chorioamnionitis

Investigation:

  • Sterile speculum exam
  • Avoid digital > risk of infection
  • Nitrazine sticks to detect pH change
  • Ultrasound (oligohydramnios as it has leaked out)
23
Q

PPROM mx [4]

DDX between preterm labour

A

Admit
Regular observation to ensure chorioamnionitis not developing
Rx: oral erythromycin 10d, CCS
IOL at 34w

Premature onset of contractions = preterm labour
Presentation of PPROM involves NO contractions

24
Q

Tocolysis contraindications for:
Indomethacin
Terbutaline

A

Indomethacin is contraindicated in the presence of aspirin-induced asthma, coagulopathy, or significant liver disease.
Terbutaline:
- Cardiac arrhythmia
- Valvular disease, IHD

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